Provider Demographics
NPI:1598860512
Name:WILSON, KATHRYN A (MD)
Entity Type:Individual
Prefix:
First Name:KATHRYN
Middle Name:A
Last Name:WILSON
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:611 W. PARK ST.
Mailing Address - Street 2:BWPC
Mailing Address - City:URBANA
Mailing Address - State:IL
Mailing Address - Zip Code:61801-2500
Mailing Address - Country:US
Mailing Address - Phone:217-383-6792
Mailing Address - Fax:217-383-4752
Practice Address - Street 1:1813 W. KIRBY AVENUE
Practice Address - Street 2:ENDOCRINOLOGY
Practice Address - City:CHAMPAIGN
Practice Address - State:IL
Practice Address - Zip Code:61821
Practice Address - Country:US
Practice Address - Phone:217-383-3490
Practice Address - Fax:217-383-3439
Is Sole Proprietor?:No
Enumeration Date:2006-09-14
Last Update Date:2014-05-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036080035207RE0101X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RE0101XAllopathic & Osteopathic PhysiciansInternal MedicineEndocrinology, Diabetes & Metabolism
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL830000434OtherMEDICARE RAILROAD PIN
ILIL3270037Medicare PIN
IL208905195Medicare PIN
ILD88948Medicare UPIN